La psychiatrie et les disciplines extrinsèques. Ouvertures et compositions

ObjectivesPsychiatry as a discipline is oriented towards the other and towards otherness; not only that of the patient and of their psychological issues, but also for the alterity of external knowledge. Recognizing its own limitations and its inability to think alone, psychiatry, whose specific knowledge is undoubtedly quite limited, has since the beginning turned to other disciplines. This article does not try to propose a new model likely to articulate this conceptual heterogeneity, but tries to understand how this movement of opening towards other disciplines is carried out. Psychiatry undeniably finds a richness in this, but does not its subservience to currents that are external to it risk accentuating its dissolution and making its identity disappear?MethodBased on the distinction proposed by G. Lantéri-Laura between intrinsic disciplines (i.e. clinical disciplines such as neurology, psychoanalysis) and extrinsic disciplines, which use a theoretical elaboration that owes nothing to clinical engagement with subjects (such as anthropology, history, or linguistics), this article will endeavor to show the contribution of extrinsic disciplines throughout the history of psychiatry, using a number of specific cases.ResultsThis article describes several ways in which psychiatry is linked to extrinsic knowledge, focusing more specifically on the human and social sciences and on history. Firstly, we study the movement by which psychiatry seeks support for its practice, an ethic of care, and even a critical ‘third eye’ that can offer it this perspective on a practice that is often decried. Secondly, this study proposes to examine the extent to which psychiatry, through the knowledge that it isolates concerning the question of madness, opens up by itself to a questioning of humanity that can be taken into account by other disciplines. Sociology shows, in particular, how clinical categories can be linked to the prejudices and ideals of a culture and an era. History shows how an event such as Pinel's liberation from chains can benefit from historical interpretations, the meanings of which are never exhausted.DiscussionPsychiatry is inspired by other knowledges, but this borrowing is often based on displacements that reflect the need to adapt to clinical issues. This extrinsic knowledge is never imported without transformation and without some infidelity.ConclusionRe-examining what is most obvious, questioning what seems most customary, these are the benefits that psychiatry can obtain by choosing to decentralize and to call upon disciplines extrinsic to the clinical. The inclusion of the human and social sciences in the understanding of psychological disorders is now well established. The dialogue that results from the meeting of heterogeneous disciplines is not intended to lead to a consensus. The clinical practice of psychiatry retains strong specificities linked to the exercise of the encounter with mental disorder. The resulting knowledge is irreducible to other disciplines. The psychiatric act is based on a responsibility incumbent on the clinician alone, irremediably divided by the issues he or she must face.     

Pratique clinique et pluralismes en psychiatrie

IntroductionThe consideration of a plurality of perspectives is highlighted in a various number of medical and scientific disciplines. For example, in psychiatry, many attempts claiming to be pluralism have been carried out over the course of the discipline, e.g. Kraepelinian and Meyerian approaches, biopsychosocial model, Jasperian approach or Freudian psychoanalytic model. At the same time, the starting point for Jean Garrabé’s views on psychiatric nosology refers to his consideration for the existence of different perspectives in the psychiatric landscape. The objective of this article is to highlight possible continuities between the Jean Garrabé’s developments and contemporary nosological issues. We will start from one of his leitmotifs, i.e. “History can inform the construction of psychiatric classifications”.MethodIn the first part, we present the diversity of perspectives in Philosophy of Psychiatry and in Philosophy of Science. In the second part, we will see how Jean Garrabé was able to discuss, in a more or less structured and explicit manner, three axes currently and widely studied in the proposals for contemporary models of psychiatry.ResultsIn a first part, we analyze the integration of Jean Garrabé into the general debates of the philosophy of science and modelisation. We will thus develop three examples of modelisation, based on contemporary psychiatric classifications, to testify this integration. The first example corresponds to staging models, which consider that psychiatric disorders could be better understood as subgroups of evolving elements – rather than as fixed categories in time. Indeed, staging models allow a sub-classification of psychiatric disorders according to their dynamical progression. The second example concerns the Hierarchical Taxonomy of Psychopathology project, which describes psychiatric disorders according to a continuum of quantitative variations, hierarchized in several dimensions. The third example concerns the Research Domain Criteria initiative, which targets some dimensions of mental functioning, i.e. areas of research from contemporary cognitive neurosciences allowing to organize psychiatric research on specific neuroscientific constructs. In a second part of this article, we analyze three axes developed both within the proposals of contemporary models and classifications and the Jean Garrabé’s views, namely dynamics, hierarchy and dimensionality of psychiatric disorders.Discussion and conclusionJean Garrabé’s conceptions seem marked by the footprint of pluralism and the three identified axes. The first axe concerns his interest for the temporal dynamics of psychopathological phenomena, evolving in time in a synchronic and diachronic manner. The second concerns his interest in the hierarchy of disorders and semiological elements, e.g. through validity or statistical analyzes. The third axe corresponds to the Jean Garrabé’s interest for the dimensionality, which considers elements underlying psychiatric disorders, whether they are phenomenological or physiopathological.     

Les échanges franco-mexicains en psychiatrie. Hommage à Jean Garrabé (1931–2020)

ObjectiveIn this text, the aim is to present the history of the exchanges between French and Mexican psychiatry in order to show their richness, parallel to the major influence of the model of Mexico's imposing American neighbor.MethodThis text follows the chronology of these exchanges, detailing the most prestigious invitations, colloquia, congresses, publications, the various psychiatrists and psychologists who participated in creating these links, on the French side and the Mexican side, as well as the various associations and federations. These illustrations are nourished by the first-hand experience of two of the authors who played a central role in these exchanges. Two areas are addressed: intellectual exchanges (conferences, presentations, books, etc.) and institutional links (mutual internships, etc.).ResultsThe article testifies to a rich tradition of exchange that has been kept alive since its inception, step by step.DiscussionAlthough the presentation of the article follows the chronology, it is possible to draw a lesson for the future, as it seems that the French model offers a counterweight to the predominant American model. We will present the anthropological and ethnopsychiatric work of one of the authors in Mexico, who drew heavily on the French example and who is institutionally implanted in both France and Mexico. We will also present the initiative of another author, a project to diversify care in Mexico inspired by the French sector model and its institutional proposals.ConclusionThis article accounts for an already rich tradition, but it also wants to be part of the continuity of the link, which, thanks to the initiatives of the present, will be able to maintain itself and remain dynamic.     

De l’épistémologie de la psychiatrie à une épistémologie psychanalytique. Entretien avec Paul Bercherie, 17 avril 2021

ObjectiveThis interview with the psychiatrist and psychoanalyst Dr. Paul Bercherie attempts to mobilize the major questions that traverse the epistemology of psychiatry and of psychoanalysis. Our conversation covers his work on classical psychiatric knowledge–the subject of his doctoral dissertation–as well as more recent work that questions the conceptual geography of the contemporary psychoanalytic field.MethodIn this open conversation, Paul Bercherie speaks about his training at the end of the 1960s, his various experiences of analysis, and his research path, which led him to develop a singular method of investigation at the interface between practice and theory. The richness of this unique journey is also supported by numerous references to the intellectual context of the time.ResultsReturning to the foundations of psychiatry allows us to revisit the complexity of these texts and illustrates the fruitfulness of the dialogue between French and German psychiatry, which nevertheless has the same objectivist and organicist basis. The author also sheds light on the inconsistency of certain nosographic elaborations. A second series of works serves to resituate Freud in his theoretical context. It results in the demonstration that the discovery of the unconscious is developed within a dated theoretical framework that is poorly suited to its innovation.DiscussionThe Freudian subject of autonomy, the perceptive, cognitive subject, which was that of classical psychology and philosophy, will be called into question by the theories of structuralism, which bases the subject on a heteronomous theory, in which the latter is conceived as a response to the linguistic and social structures which determine it.ConclusionsContemporary psychoanalysis unfolds in the form of separate currents, based on different ethical and theoretical conceptions. However, an analysis shows that the four main currents are individualized from different dimensions already included in the Freudian text. Paul Bercherie argues that these currents should not only be opposed but, instead, that they could benefit from being integrated into a multi-referential clinical orientation. This makes it possible to offer differential but complementary approaches for the patient.     

Pédopsychiatrie et Handicap Réflexions sur cinquante ans de changements

An overview of the five different and successive meanings attributed to the word “Disability” during the past 50 years. First, the fixed deficit opposed to the notion of a progressive disease (Law of 1975). Second, the disabling process, a consequence of the psychiatric illness (CIH 1980). Third, the handicap developmental disorder, the anti-psychiatric flag of the parents of autistic children (Chossy Law of 1996). Fourth, the situational disability, detached from the state of the person and emphasizing the relationship of the person with his or her environment (CIF 2001). Fifth, the elimination of disability in favor of difference in an ideally inclusive society (2014–2022). The articulation of these transformations in the practices of child and juvenile psychiatry intersectors was established in 1972.ConclusionThese changes in meaning were accompanied by a continuous improvement in the quality of life for children in need of ongoing substantial support. The word handicap seems to have served to seal the unthinkable of chronicity during childhood, this bio-psycho-social reality contrary to the ordinary evolutionary representations of the child psyche and to the anthropological evidence of growth.     

Des logiques en psychiatrie. Application, paradoxes, réunification

Logic sets down a fundamental problem in psychiatry on account of its field and mode of application, and because of the tool of thought used. Consequences result from it concerning the relations between form and contents, as well as between theories and practice. After having reminded the reader of the great lines of classical logic based on the third-excluded and a logic meant for a world of energy centred on a third-included, we analyse their relationships. The paradoxes resulting from their application to psychiatry are mentioned. A model reunifying these logics is consequently considered, making it possible to approach a field of logical homogeneous knowledge in psychiatry. A conclusion underlines the practical consequences of it. It concerns the use of logics in order to give a better frame to psychiatric knowledge, the estimation of the data obtained, the theories considered as well as to the orientation of our discipline with the resort to new tools of knowledge.     

Le psychotrauma. Stress et trauma. Considérations historiques

Historical consideration will cover four periods in the history of trauma: the precursors; the founders; the upholders; the innovators. A necessary distinction between stress and trauma will then be made so as to better conceive the notion of trauma.     

The electrode,the brain and the mind

Conclusion Finally, the brain does function as an integrated whole in one sense. But there are semi-separable mechanisms within that integration. We must continue to study them. This is the way of progress that was begun for us by Fritsch and Hitzig, and Charcot and Jackson.As scientists, we should reserve judgment as to the ultimate nature of things. Meantime we can only use the language of dualism, and speak thus of the mind and the brain. There is no other medium of analytical discussion. The ancient riddle of how brain and mind do interact is still unsolved. But, we begin to understand the brain, if not the mind. The mind receives messages. It seems to direct brain action in the focussing of attention and in voluntary activity.There is a special mechanism for the mind. It can be activated from a distance by an electrode on the interpretive cortex. The mechanism is sometimes arrested by epileptic discharge in centrally placed gray matter. During this activation, consciousness is not lost. During this arrest, consciousness is lost and since other mechanisms continue without control from the mind's mechanism, the individual becomes an automaton.Fritsch and Hitzig had stumbled upon the truth. The brain does function, as they said, by isolated mechanical means. And we can now perceive the outline of a further truth: The mind is matched by a specific corresponding mechanism in the brain. Human behaviour is determined by interaction of brain and mind.The Fritsch and Hitzig Centennial Lecture, Deutsche Gesellschaft für Neurologie and La Société Neurologique de France, München, October 8, 1970.     

Epilepsy in The Alienist and Neurologist, 1880-1920

PURPOSE: To study the history of epilepsy from 1880 to 1920. METHODS: We reviewed all 40 volumes of The Alienist and Neurologist and identified articles concerning primarily epilepsy. We analyzed three of these articles in greater detail. RESULTS: The Alienist and Neurologist published "Original Contributions,"Selections," (abstracts from other journals written by the editorial board), "Editorials," and (book) "Reviews." Of 258 epilepsy articles, there were 40 Original Contributions, 164 Selections, 39 Editorials, and 15 Reviews. These articles included 71 on therapy (41 medication, 13 surgery, and 17 other therapies); 66 general discussions; 46 on etiology or symptoms; 34 case studies; 28 social/legal articles; and 13 autopsy or pathology articles. CONCLUSIONS: Analysis of The Alienist and Neurologist provides a unique and valuable perspective on the clinical practice and academic world of epileptology during the decades around the turn of the twentieth century.     

L’essor irrésistible d’une discipline abolie : la neuropsychiatrie en France (1968–2018)…

The future of psychiatry is a regular concern for the profession. This quest for identity, often tinged with references to human values, such as ethics, aims to defend such an approach against such a reference system. In the background, the scientific evolution of psychiatry in favor of neuroscience emerges as a sense of threat. The fear would then be a dissolution of psychiatry within (too) medicalized neuropsychiatry. Indeed, this discipline, though abolished during the reworking of medical studies, following the events of May 68 in France, seems more alive than ever. We will see that the conception of the nature of disorders, between neurogenesis and psychogenesis, is at the heart of this problem, and has been raging for a long time. But if fears and debates are willingly exposed in the press, few messages of hope and reconciliation between neurology and psychiatry find their place. This will be the object of our reflection, which aims to defend the interest of an integrative approach in (neuro?) psychiatry without sacrificing scientific knowledge or the dynamics of subjective truth to the achievement of our art.     

Giovanni Brugnoli and the origin of neuropsychology in Italy

The paper reports an unknown episode of the history of Neurology in Italy, namely the first Italian contribution to the discussion about the cerebral localization of articulate speech.

---

Sommario Viene riportato un episodio sconosciuto della storia della Neurologia in Italia, e cioè il primo contributo italiano alla discussione sulla localizzazione del linguaggio.

     

Clinical trials of N-acetylcysteine in psychiatry and neurology: A systematic review

N-acetylcysteine (NAC) is recognized for its role in acetaminophen overdose and as a mucolytic. Over the past decade, there has been growing evidence for the use of NAC in treating psychiatric and neurological disorders, considering its role in attenuating pathophysiological processes associated with these disorders, including oxidative stress, apoptosis, mitochondrial dysfunction, neuroinflammation and glutamate and dopamine dysregulation. In this systematic review we find favorable evidence for the use of NAC in several psychiatric and neurological disorders, particularly autism, Alzheimer's disease, cocaine and cannabis addiction, bipolar disorder, depression, trichotillomania, nail biting, skin picking, obsessive-compulsive disorder, schizophrenia, drug-induced neuropathy and progressive myoclonic epilepsy. Disorders such as anxiety, attention deficit hyperactivity disorder and mild traumatic brain injury have preliminary evidence and require larger confirmatory studies while current evidence does not support the use of NAC in gambling, methamphetamine and nicotine addictions and amyotrophic lateral sclerosis. Overall, NAC treatment appears to be safe and tolerable. Further well designed, larger controlled trials are needed for specific psychiatric and neurological disorders where the evidence is favorable.     

Mise en place et évaluation de séances d’éthique appliquée dans un service de psychiatrie générale en France

IntroductionEthics of care allows questioning of the values and the meaning of clinical practice for the patient. Psychiatry is a medical discipline in which the complexity of decisions is frequently linked to ethical issues. Moral Case Deliberations (MCD) are clinical ethic supports to explore these issues and to analyze value conflicts. However, there is no study yet in France on the implementation of Moral Case Deliberations.ObjectivesOur main objective is to evaluate the efficiency of MCD in a general psychiatry unit. The secondary objective is to point out the topics discussed by participants at each MCD session.Materials and methodSix MCD were organized in a psychiatric care unit. All caregivers were invited to participate without exclusion criteria. A questionnaire was developed for this study using data from international literature. The questionnaire was elaborated to collect information on the main effects expected of MCD and their general organization. Reports have been established for each session, summarizing the exchanges between participants.ResultsA total of 23 participants answered the questionnaire one month after the end of MCD sessions. Quantitative analysis of the questionnaire revealed positive effects of MCD in a psychiatric care unit (response considered as positive when higher than 70%). The most positive effects were that MCD are a different tool from common practice and that it allows questioning of quality of care. The general organization of MCD was also considered positive especially because of the possibility of expressing oneself freely. Qualitative analysis identified the main themes as ethically sensitive in the daily psychiatric practice: endangerment and protection, social consequences of psychiatric disorder, diagnosis and therapeutic alliance.ConclusionsOur study confirms the utility of practicing MCD in a psychiatric unit. Their implementation reflects a change in the conception of ethics, from theoretical to practical. MCD refer to practical ethics dealing with ethically sensitive everyday situations, particularly frequent in psychiatry. MCD are an original and innovative method to meet French requirements on hospital ethics. They can be considered as a method of improving professional practices.     

Foisonnement imaginaire et délire paraphrénique dans La Tempête de Shakespeare

ObjectivesTo show, through the figure of Prospero (the “magician” of the Shakespeare's Tempest) the clinical specificity of fantastic paraphrenia: overflowing imaginary, luxuriance of delusion with fantastic and cosmic themes, “diplopia” between the imaginary world and the real world (H. Ey), megalomaniac dimension, etc.MethodA review of the literature will give us the essential elements to understand the singularity and personality of Prospero. These elements will logically lead us to say a few words about paraphrenia–and especially in its fantastic form–by taking our references both in the field of psychiatry (H. Ey) at the same time in the field of psychoanalysis (J. Lacan). Finally, we will conclude by emphasizing two fundamental aspects of paraphrenia that appear quite clearly in Prospero: the “exceptional” identity, and the imaginary proliferation.ResultsIf the character of Prospero, of course, cannot be considered a “clinical” case, the complexity of the character, the intelligence of Shakespeare, his sense of “clinical” observation, invite us to read The Tempest as the paraphrenic delusion of a dethroned Duke, driven by vengeance, persuaded to command Spirits and Nature. In addition, the “power” of paraphrenic delusion will also be grasped, in that it allows do distance, and to control an Other persecutor.DiscussionThe discussion concerns what is signing the stucture of “fantastic paraphrenia” from the psychiatric's and psychoanalytic's point of view, among other things the formation of an “exceptional” identity with megalomaniac colors, omnipotence, “diplopia” between the real world and the imaginary world, the imaginary proliferation, the luxuriance of the delusion, the “consent to the enjoyment of the Other” (Maleval).ConclusionShakespeare has given us, in his immense work, an important view of “psychopatic characters on stage” – to use a Freud's title – with an almost unmatched “clinical” fineness. This is the case for King Lear, for Othello, Macbeth, Hamlet, Richard III, Timon of Athens, Titus Andronicus, and many others. Prospero, in our opinion, can be part of this lineage. The “hypertrophy of the Self”, the imaginary proliferation, the grandiose themes unfolded, the demiurge and theurge incarnated give the feeling – with our current landmarks – to assist in a certain sense to the development of a fantastic paraphrenia.     

Revaloriser la dimension du contact en psychiatrie. Du Praecox Gefülh à un outil de typification des formes d’existence humaine

ObjectivesThe clinician who adopts a psychoanalytic approach in a psychiatric context often regards the encounter between two individuals as an interplay of subjectivities, whose mode of being-in-the-world is shaped by their unique historical experiences. Despite some psychoanalytic authors exploring the concept of “contact,” it has often been reduced to its similarity with transference and countertransference, with little attention given to its distinctive qualities. This limits psychoanalysis in its ability to conceptualize an unmediated, preverbal encounter between two individuals. In this article, we argue that the dimension of “contact” cannot be equated with transference, and that it constitutes a vital tool for diagnosing and guiding therapy for various clinical conditions commonly encountered in psychiatry.MethodThis article is based on theoretical considerations. We first worked on the history of the concept of contact, then of Praecox Gefühl in the works of H.C. Rümke, to which we added the findings of current studies on the relevance of Praecox Gefühl in the diagnosis of schizophrenia and the study of the works of the great phenomenological psychiatrists. In so doing, we aimed to show that contact could be a tool of great use for psychiatric diagnosis, insofar that it allows for a typification of the forms of existence of different patients.ResultsH.C. Rümke's investigation of the concept of Praecox Gefühl highlights the unique mode of contact observed in schizophrenia. It is distinct from the feeling of strangeness and involves an intuitive observation of a perceived distance within the clinical relationship. Given that many psychiatric pathologies can cause patients to withdraw from the shared world, we suggest that the notion of Praecox Gefühl, beyond its original designation of the clinician's experience of schizophrenic dissociation and the particularities of the schizophrenic mode of being-in-the-world, may be applicable to other pathologies studied in psychiatric phenomenology. We propose four main forms of contact: the loss of vitality in schizophrenia, the untraceable authenticity of the hysteric, the impossible fluidity in the melancholic, and the failure of anchorage in mania. By approaching contact as a fractal form that reveals the entire mode of the subject's being-in-the-world, this typifying approach goes beyond a purely semiological or etiological reflection and can be diagnostically useful in guiding therapeutic efforts to enhance the subject's capacity to truly engage with others.DiscussionOur paper focuses on the relationship between contact and what clinicians commonly refer to as an “encounter”. It is important to recognize that contact is not always equivalent to an encounter, and that assuming otherwise risks overlooking the possibility that certain relational modalities could actively prevent such an encounter from taking place. These “anti-contact” modalities, exemplified by the Praecox Gefühl, necessitate a focus on the very possibility of being in a therapeutic relationship with the clinician. Therefore, we suggest that clinicians should work to establish the possibility of being in a relation with the patient, prior to attempting to create an encounter. This approach allows for a more nuanced understanding of the ways in which patients can either facilitate or hinder the development of an encounter, and highlights the importance of working on establishing the possibility of a real encounter and being-with the clinician.ConclusionThis paper has sought to challenge the prevailing assumption among psychoanalytically oriented clinicians that contact is merely a sub-dimension of the transferential dynamic. Instead, we have argued that contact warrants specific attention as a tool for both diagnosis and therapy in psychiatry. By examining the example of the Praecox Gefülh, we have proposed a typifying approach that could be applied to the most common clinical entities encountered in psychiatry, based on the clinician's perception of specific modalities of contact within the therapeutic consultation. This reflection on contact and anti-contact is a necessary and contemporary contribution to the psychiatric field, which is increasingly embracing a dimensional approach to psychological pathologies. By prioritizing the dimension of contact, we can deepen our understanding of the nuances of the therapeutic relationship and can enhance our ability to help patients overcome barriers to connection and encounter.